Cytoreductive surgery to minimize residual tumor followed by platinum- and taxane-based chemotherapy is the standard treatment for advanced epithelial ovarian cancer [18].

Management first requires surgical staging in the form of staging laparotomy, and at this time approximately 30 % of patients are upstaged [20].

Total abdominal hysterectomy and bilateral oophorectomy alone are performed for stage I disease. Cytoreductive surgery is carried out for patients with stage II–IV disease [20–22, 23]. This is followed by systemic platinum-based chemotherapy [12].

For patients with bulky stage III/IV disease who are not surgical candidates, neoadjuvant chemotherapy followed by primary cytoreduction can be considered [16, 24–27].

As early as 1935 Meigs recognized the importance of cytoreduction and removing as much tumor as possible to improve the effects of postoperative radiation in the management of ovarian cancer [28]. Forty years later Griffiths published a study that demonstrated conclusively an inverse relationship between the maximal residual tumor diameter and patient survival [29].

Cytoreductive surgery or debulking is the standard treatment recommendation for patients with clinical stage II–IV disease [20–23]. Cytoreductive surgery can be performed at the time of index surgery termed primary cytoreduction, following neoadjuvant chemotherapy, or for recurrent disease termed secondary cytoreduction.

The aim of cytoreduction is to fully stage the disease and achieve maximal clearance to less than 1 cm residual disease, or resection of all visible disease in appropriate circumstances.

Procedures that may be considered for optimal surgical cytoreduction include radical pelvic dissection, omentectomy, bowel resection, diaphragm stripping, splenectomy, partial hepatectomy, and distal pancreatectomy [30].

Chi et al. studied the impact of extensive upper abdominal primary cytoreduction including splenectomy, distal pancreatectomy, hepatic resection, and resection of porta hepatis tumors (Group 2) compared to earlier more conservative cytoreduction which involved only TAH, BSO ± omentectomy, and bowel resection (Group 1). Optimal cytoreduction rates defined as <1 cm residual disease (total disease less than 1 cm left behind) increased from 50 to 70 % between groups 1 and 2.

Operative time and estimated blood loss were greater in group 2 than group 1, P < 0.001 for both; however, complication rates and length of hospitalization were not significantly different between the two groups [31].

For patients with bulky stage III/IV disease who are not surgical candidates, neoadjuvant chemotherapy followed by primary interval cytoreduction can be considered [16, 24, 26, 27, 32].

Secondary cytoreductive surgery can be considered for patients who experience recurrence after a long disease-free interval (>6 months) [33].

Ovarian malignancy can disseminate to the liver via intraperitoneal seeding or hematogenous spread.

With peritoneal seeding, initially the cells move downward into the pelvis due to the pull of gravity, and they then travel cranially in the circulating peritoneal fluid, moving through the right paracolic gutter to the pouch of Morrison and the right subdiaphragmatic space. The peritoneal fluid from the posterior subphrenic space travels along the right coronary ligament to the hepatic bare area and spreads throughout the perihepatic space.

The tumor cells initially seed to the liver capsule producing peritoneal lesion on the liver surface – stage III disease. The tumor can then advance to involve the liver parenchyma – stage IV disease [16, 18].

Hematogenous spread is generally seen in advanced disease the liver being affected in 48 % of cases.

Liver involvement can be present at the initial diagnosis of ovarian cancer usually due to peritoneal seeding, and the presence of adhesions resembling those seen in Fitz-Hugh-Curtis disease may be an early indicator of carcinomatosis [16].

Alternatively metachronous liver metastasis diagnosed during follow-up following initial cytoreduction and chemotherapy can occur. These can be either due to peritoneal seeding or hematogenous spread.

As stated liver involvement can therefore occur in both stage III and IV disease. Sixteen percent of ovarian cancer cases are stage IV at the time of diagnosis. Both stages of ovarian cancer have a poor prognosis with 5-year survival for stage III and IV disease approximately 37 and 25 %, respectively [34–36].

When considering liver resection in ovarian cancer metastasis, consideration needs to be given to the stage of disease and whether the tumor is synchronous or metachronous.

Liver resection has been considered in the setting of:

The literature surrounding liver resection for ovarian malignancy is limited and mainly restricted to retrospective reviews.

The majority of papers have reviewed the role of hepatic resection in secondary cytoreduction for recurrent disease following chemotherapy.

Liver resection has been carried out in the context of both stage III and IV disease, with and without the presence of extrahepatic disease. Resection was performed for both single and multiple metastases [37–43].

Median survival ranged from 11 to 62 months combining stage III and IV disease. Two studies looking at only stage IV had wide variation in median survival, 11 and 40 months [40]. Similar survival rates are seen with and without the presence of extrahepatic disease [38, 39, 41, 43].

There was no perioperative mortality reported, and complication rates are reported between 11 and 21 %. All studies had a long median disease-free interval ranged between primary cytoreduction and the development of liver metastasis ranging 32–68.5 months.

Both univariate and multivariate analysis demonstrated the importance of length of disease free interval to the development of liver metastases as a good prognostic factor. This possibly indicates favorable tumor biology. Other prognostic factors include optimal cytoreduction of residual disease to <1 cm and clear surgical margins, survival of 52 months with R0 resection compared to 22 months R1 [38]. Nui et al. found that the number of liver lesions affected prognosis [38], and this was however not found by others [37]. Abood et al. demonstrated improved prognosis if the size of the largest metastatic tumor was >5 cm, and speculating this may be due to overall less tumor burden due to smaller number of tumors [42].

Liver resection can be considered for both single and multiple liver lesions. The presence of extrahepatic disease should not exclude liver resection as long as adequate debulking is possible. Neoadjuvant chemotherapy can be performed in the presence of bulky stage IIIc/IV disease in an attempt to downstage the tumor and improve the chance of tumor clearance and achieving an R0 resection. In addition it may reduce the extent of resection required and therefore the possible surgical morbidity.

The patients considered for liver resection, as with other hepatic metastases, should have good performance status. Many of the patients undergoing secondary cytoreduction and liver resection subsequently completed a further course of adjuvant chemotherapy (Table 7.2).